Keenan Public Agencies - Resources

Documents & Forms

APPLE
Workers' Comp
WC Claims Kit
Benefits

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APPLE Beneficiary Designation and Change FormNeed to change your beneficiary on your APPLE plan? Download this form.
APPLE Request for Settlement of Account (RSA)Request a distribution from your APPLE plan.
APPLE Rollover Contribution Request FormRoll funds into your APPLE plan from another qualified plan.
APPLE Request for Refund of Contribution FormPlan Sponsor form to request a refund of contributions made in error.
APPLE Request FormGet a quote to see how an APPLE plan can benefit your organization.
APPLE Participant Web Site Access Instructional FlyerInstructions for APPLE plan members to access their account info online.
APPLE Plan Sponsor Web Site Access Instructional FlyerInstructions for APPLE plan sponsors to access the management website.

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PRIME Rx Introductory LetterIntroduction to Prime Rx for program administrators.
PRIME Rx Temporary Prescription Services IDWC Temporary Prescription Services ID form that can be presented to your pharmacist when you fill your initial prescription using the Prime Rx program.

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Briefing - Division of Workers' Compensation Amends MPN and Employee Information RegulationsThe Department of Workers' Compensation marks a milestone in their 12-point plan focused on reducing workers' compensation costs, with the issuance of new regulations for MPN and employee information requirements.				Published 9/10
Briefing - Predesignations March 2006These rules and regulations provide clarification regarding how an injured employee must predesignate their personal treating physician and exactly what type of physicians can be predesignated.				Published 3/06
WC Benefits SummaryInformation about your Workers' Comp benefits.				Revised 7/10
Posting NoticeFlyer to post that explains what to do when an injury occurs at work.				Revised 9/11
New Hire PamphletHand-out for employees that explains Workers' Comp benefits.				Revised 8/10
MPN Employee NotificationMPN Employee Form
Personal Physician Request and Acknowledgement FormYou must notify your employer ,in writing, prior to being injured on the job and provide written verification that your personal physician meets the above requirements and agrees to be predesignated to be eligible.				Revised 7/07
Notice of Personal Chiropractor or Personal Acupuncturist FormTo be eligible you must notify your employer in writing prior to being injured.
Notice of Potential Eligibility/DWC-1Instructions for submitting a Workers' Comp claim.				State Version 6/10
DWC-1 Claim FormState of California Workers' Comp Claim Form.				State Version 6/10
Compliance Kit Order FormOrder printed copies of the WC forms to be mailed to your organization.				Revised 8/10

If you are a School or Community College customer, please click here and then click on the "Benefits" tab to download your Administrative Guides.

Name	Protected	Download		Notes
		English	Spanish
Benefit Eligibilty Contributions Form
COBRA Continuation Coverage Administration ManualQuick reference and easy access to the tools you need for COBRA administration.				updated for 2010
COBRA Continuation Coverage Administration Manual FormsQuick reference and easy access to the tools you need for COBRA administration.				updated for 2010
Health Plan's Authorization FormThis form is used to request an individual’s unconditioned authorization for the Health Plan to use or disclose protected health information for the purpose stated.
HIPAA Resource GuideInformation guide about HIPAA regulations.				updated for 2010
Prudential Basic Life/AD&D, Optional Life/AD&D Public Agencies Administrative GuideThis Admin Guide is designed to assist you in the administration of your Life and AD&D Program.				Updated 8/19/11
Prudential LTD Public Agencies Administrative GuideThis Administration Guide is provided to assist you with your Long Term Disability Program.				updated 8/15/11
Prudential STD Only or STD & LTD Public Agencies Administrative GuideThis Administration Guide is provided to assist you with your Short Term and/or Long Term Disability Program.				Updated 8/15/11